Anatomy, Imaging, and Common Pain-Generating Degenerative Pathologies of the Spine

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Anatomy, Imaging, and Common Pain-Generating
Degenerative Pathologies of the Spine

• R2 ???

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ANTOMY

• Osseous spinal column
• 7 cervical, 12 thoracic, 5 lumbar and 5 fused
  sacral segments
• C1 (atlas) anterior arch, posterior arch,
  and paired lateral masses
• C2 (axis) bony projection which articulate
  with C1 (odontoid process or dens)
• C3 C7 dorsolateral margin of the superior
  endplate (uncinate process)
• typical cervical, thoracic, and lumbar vertebra
  anterior body, paired pedicles, articular pillars
  and laminae, and a single dorsal midline spinous
  process

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• Spinous process serve as a attachment point for
  the posterior ligamentous structures
• Pedicle, articular pillars, and lamina - serve to
  protect the spinal cord and nerve roots
• Transverse process
• in the mid-cervical vertebral artery? ????
  osseous transverse foramina? ??
• in the thoracic and lumbar spine spinal
  column? protect?? stabilize??? muscle? ?? ???
  ???.

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• Joints
• atlanto-occipital occipital condyle lateral
  mass of C1
• Atlantoaxial ventral dens dorsal surface of
  C1 anterior arch
• Uncovertebral dorsolateral margin of the
  superior endplate of the C3C7
• Costovertebra and Costotransverse rib
  vertebral body or transverse process of the
  thoracic spine
• zygoapophyseal (facet) joints the most
  prevalent joints , superior and inferior
  articular process

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• Transverse foramen, Intervertebral foramen, and
  Nerve roots
• Contents of Transverse foramen vertebral
  artery, vertebral venous plexus, sympathetic
  chain
• Intervertebral foramen
• bounded by the pedicle, vertebral body, disc and
  superior articular process
• - Adamkiewicz artery supply to the lower
  two-thirds of the spinal cord , enter the spinal
  canal via an intervertebral foramen
• -gt transforaminal or periganglionic
  intervention? damage? ??
• Intervertebral Discs thicker in the cervical
  and lumbar region and thicker anteriorly than
  posteriorly
• - axial loading ? absorb, flexibility??
• - nucleus pulposus, annulus fibrosis,
  cartilaginous endplate

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• - nucleus pulposus type II collagen,
  hyaluronic acid, glycoaminoglycan
• - annulus fibrosis outer dense circumferential
  fibrous band and inner fibrocartilagenous layer
• Ligament stability, flexion, extension,
  rotation
• - ALL, PLL, ligamentum flavum, interspinous
  ligament, supraspinous ligament
• - ALL vertebral body and intervertebral disc
• - PLL annulus fibrosis but does not contact
  the posterior vertebral margin
• - ligamentum flavum laminar segment ???
  extend, spinal canal? dorsolateral margin? define
• - interspinous ligament, supraspinous lig.
  spinous process ??? ??

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IMAGING OVERVIEW

• Conventional Radiographs (X-rays)
• - quick, inexpensive, easy to perform,
  execellent spatial resolution
• - important information alignment, structure,
  mineralization
• - unstable spine dynamic, weight bearing
  upright flextion and extension view
• - foraminal stenosis, spondylolysis oblique
  projection
• - vertebra alignment evaluate lateral
  projection ?? three longitudinal curve ( anterior
  and posterior spinal line anterior and
  posterior longitudinal ligament ? course ,
  spinolaminar line ligamentum flavum ? course )
  ? pedicle? ???? rotational malalignment? ???.

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• Myelography and postmyelography CT scan
• - non-ionic, water-soluble, radiographically
  dense iodinated contrast material? subarachnoid
  space? ??? spinal canal? content? evaluate??
  radiographic technique.
• - disc abnormality, ligament thickening,
  hypertrophic facet degenerative change, spinal
  stenosis, nerve root impingement, redundant
  thickened nerve root, arachnoiditis can be
  detected
• - postmyelography CT scan better definition of
  anatomic relationship of the contents of the
  spinal canal to the surrounding structure
• - invasiveness and non-invasive imaging
  tool(CT, MRI)? availability? ?? ??? ???.
• - Cx. positional headache(m/c),
  contrast-related seizure, infection

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• Computer-assisted tomography (CAT or CT scan)
• - osseous structure? definition? ?? ??.
• - x-ray beam? diffenrential attenuation? ???
  ???, bone, ligament, disc material, CSF ??
  radiographic density??? ????, disc herniation,
  ligamentous disorder?? ????? ??? ? ??.
• - spinal rods, transpedicular screw, laminar
  wire/hook, intervertebral cage?? surgical
  metallic implant? ?? artifact? ??.
• - children, pregnant female, other young adult??
  ? sensitive??? ??? care?? ???? ?.

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• Magnetic resonance imaging(MRI)
• - hydrogen atom(proton)? amount and state? ????
  tissue? localize?? ?? gradient field?
  radiofrequency? ??
• - radiation? ???, electrical and metal implant?
  ?? risk? fetus? ?? unknown risk? ??.
• - soft tissue contrast resolution? ???? spinal
  disorder? diagnostic imaging modality? ???.
• - bone marrow, muscle, ligament, disc material,
  nerve root?? tissue type? ??? ????, extradural,
  intradural, extramedullary, intramedullary
  pathology? ??? ???.
• - medullary bone evaluation?? ???? marrow edema?
  marrow replacement? ???? osseous condition? ? ?
  ???, dense cortical bone, sclerotic lesion,
  osteophyte? ?? ???? CT? ?? ??.

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• - standard MRI protocol sagittal and axial
  with T1- and T2- weighted sequence
• - T1 high signal intensity fat (fatty bone
  marrow, subcu. Fat)
• low signal intensity fluid (CSF, bone marrow
  edema,
• normal nucleus pulposus)
• - STIR(short-tau inversion recovery) fat
  depressed T2-weighted sequence? fluid?
  sensitive?? traumatic injury, malignancy,
  infection??? edema? detect??? ??
• - GRE(gradient recalled echo) T2-weighted
  imaging? blood product and calcium? sensitive??
  spinal trauma? ??
• - infection, multiple sclerosis, intramedullary
  neoplasm, metastatic disease, postoperative
  scarring evaluation IV gadolinium contrast
  material administration sagittal and axial
  T1-weighted image

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• - C/Ix. cardiac pacemaker, metallic foreign
  body, metallic surgical implant(ex. cerebral
  aneurysm clip and heart valve)
• - MRI??? m/c problem? claustrophobia?? sedation?
  ??overcome???, ???? ??? ??? ??.

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DEGERATIVE DISC DISEASE

• Overview
• Acute or chronic back pain? ???? uncertain
  etiology, aging? ?? pathologic process
• Conventional radiographic finding disc space
  narrowing, vacuum disc, endplate sclerosis,
  ostephyte formation
• MRI excellent soft tissue contrast and
  multiplanar capability
• -gt disc degeneration evaluate? modality of
  choice
• Disc dehydration and Narrowing
• T1 hydrated and nonhydrated disc homogenous
• T2 disc? water content? bright signal -gt
  central bright nucleus pulposus and dark annular
  fibrosis

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• Degenertive disease -gt disc desiccation -gt disc
  signal??
• -gt intradiscal gas accumulation
• -gt proton ? ??? T1- and T2-?? hypointense
  sequense
• (vacuum disc phenomenon)
• Disc height? normal or diminished??? disc
  degeneration? indicator? ???, decreased height?
  intervertebral foramina size? ???? nerve root?
  compression? ???.
• Annular fissure / tears
• -On T2-weighted image, linear hyperintense
  signal
• Three type of annular degeneration concentric
  fissuring, transverse tear, radial tear
• - concentric fissuring collagen fiber
  delamination T2?? disc margin? parellel? high
  signal intensity

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• - transverse tear vertebral body ring
  apophyses? Sharpeys fiber? junction?? small foci
  of T2 hyperintensity
• - radial tear primary failure of the annulus
  and full-thickness disruption of the annulus
• outer third of annulus fibrosis and PLL are
  innervated by nociceptive nerve ending -gt
  discogenic back pain
• Subchondral marrow changes
• - vertebral end plate degenerative disease?
  three type
• T1- and T2- weighted signal charateristic? ??
• - Type I change T1??, T2?? vascularized
  marrow
• - Type II change T1??, T2?? or isointense
  bone marrow? fatty replacement
• - Type III change T1, T2 both low signal
  subchondral sclerosis

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DISC HERNIATION

• Overview
• - disc herniation evaluation imaging modality
  of choice is MRI (due to its excellent soft
  tissue resolution)
• Disc contour
• Disc herniation Intervertebral disc space? ???
  localized disc material displacement
• Circumferential bulge vertebral bodys ring
  apophysis edge? 50100? ???? disc material
  bulging
• - 25 ???? localized herniated disc material?
  focal , 2550 ? broad-based?? term
• - vertebral endplate? focal disc herniation
  Schmorls node

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• Disc margin? herniated disc fragment? shape? ??
  protrusion and extrusion?? describe.
• - protrusion base? wider than apex
• - extrusion base?? width?? herniated fragment?
  ? away
• - sequestated or free-fragment disc herniation
  parent disc?? completely seperated
• Disc migration in the cranial or caudal direction
  is best evaluated in the sagittal plane
• - ?? posterior extrusion? PLL ?? ??, inferiorly
  migrate?

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• Disc herniation position
• Disc herniation? ??? anatomic landmark? ????
  describe.
• - extraforaminal zone pedicle? lateral aspect?
  parasagittal line? ???? zone.
• - lateral recess pedicle? medial border? ???
  area, disc level and superior vertebral endplate?
  ??
• On sagittal image
• - suprapedicular level pedicle? ?? ?
  superior end plate
• - pedicle level pedicle? superior and inferior
  edge??
• - infrapedicle level pedicle? inferior edge??
  inferior end plate
• Herniated disc? ??? ?? compress?? nerve root??
• - in the Cervical spine central or paramedian
  herniation -gt descending nerve root
• ex) C3-4 paramedian disc extrusion -gt C5 nerve
  root

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• foraminal disc -gt ?? level? nerve root
• ex) C3-4 foraminal disc -gt C4 nerve root
• - in the thoracic and lumbar spine(existing root
  is associated with superior level) paramedian
  disc T3-4 -gt T4 root
• foraminal disc T3-4 -gt T3 root
• Neural compression? ??? herniated disc? ??
  normally round or oval configuration? spinal
  cord, nerve root, root ganglion? ??? ??? ??
  graded.
• - mild compression normal diameter? 7599 ??
• - moderate 5074, severe lt50

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FACET JOINT

• Overview
• - low back pain? source? ???, clinically primary
  cause?? ????? ???.
• - facet joint syndrome degenerative facet
  joint? ?????? ??? focal or referred pain? ???
  controversial diagnosis
• Imaging
• - facet joint arthropathy hypertrophic
  osteophytic overgrowth, subchondral sclerosis,
  bone marrow edema, joint space narrowing/widening,
  joint stiffness, periarticular soft tissue
  edema
• - osteophytosis and subchondral sclerosis T1-
  and T2- ?? hypointense
• - bone marrow and periarticular soft tissue
  edema T1?? hypointense and T2-??
  hyperintense??.
• - joint space widening joint space? effusion,
  T2-hyperintense

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• - facet joint arthropathy? intrinsic
  abnormality? pain??? ? ??, lateral recess??
  descending nerve root? intervertebral foramen??
  existing nerve root? compression?? pain??.
• - facet joint osteoarthritis CT scanning?? ???
  ??.
• cervical spine?? ??? sclerotic change and
  osteophyte? MRI?? ? ?? ??.

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INTRASPINAL FACET CYSTS

• Overview
• - intraspinal facet cyst facet joint ??
  origin? smooth border? fluid-filled rounded
  structure
• - lining of cyst synovial epithelial
  cell(synovial cyst) or fibrous wall surrounding
  myxoid material(ganglion cyst)
• - radiologically both type? ?? ???, treatment?
  ???? ??? type? ??? ????? ??? ??.
• - synovial cyst(??)? ?? ?? degenerated facet
  joint?? ???, joint? dorsal surface?? ?? ?? soft
  tissue? protruding??? neural structure?
  compression??? ??, ventral surface?? ???
  intervertebral joint, lateral recess, lateral
  spinal canal? protruding? ?? location? ??
  existing nerve root(in the foramen) or descending
  nerve root(in the lateral recess or lateral
  spinal canal)? compression ?
• - nociceptive synovial lining -gt intrinsically
  painful? ?? ??.

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• Imaging
• - on CT, uncomplicated synovial cyst isodense
  to CSF, occasionally has a calcified wall
• proteinaceous material or blood within cyst
  isodense to
• muscle or ligament
• - mass effect or stenosis related to intraspinal
  or foaminal synovial cyst CT myelography
• - MRI T1- and T2- prolongation, isodense to
  CSF
• proteinaceous or hemorrhagic material T1
  hyperintensity
• wall? fibrous material? ??, calcified
• - juxta-articular cyst? disc extrusion D/Dx.
  short term follow up MRI?? disc fragment?
  resolution??, cyst? no change
• - treatment conservative management,
  percutaneous decompression, sugical removal -gt
  successful outcome

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SPINAL STENOSIS

• Overview
• - CT? bony abnormality, bulging or herniated
  disc? ?? spinal stenosis? ????? evaluation
• - MRI GRE T2 image in the cervical spine and
  conventional or fast spin echo T2-weighted image
  in the T-L spine -gt canal??? CSF flow? ??
  artifact?? central canal and intervertebral
  foramen? evaluation? ? ??.
• - surgical hardware?? ???, conventional
  T2-weighted image? artifact? ??? ? ? ??.
• Grading spinal stenosis
• - AP dimension? ?? mild stenosis? normal level?
  spinal canal? AP diameter? 7599??, moderate and
  severe? 5074, lt50
• - intervertebral foramen? AP and craniocaudal
  dimension?? evaluate

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• - mild foraminal stenosis? bulging disc or
  hypertrophic superior articular process? ??
  foramen? inferior part? narrowing
• - moderate narrowing? nerve root? ??? fat? ???.
• - severe stenosis? no fat, nerve root clearly
  compressed
• ?? ??? sagittal T1-weighted sequence?? most
  sensitive

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SPONDYLOLYSIS AND SPONDYLOLISTHESIS

• Overview
• - spondylolysis articular pillar? pars
  intra-articularis??? discontinuity, ??? ??????,
  chronic microtrauma? ????? ??.
• - bilateral pars fracture???, vertebral body?
  ??? slip
• -gt spondylolisthesis
• - mild and moderate slip canal? not narrow,
  paradoxically enlarge
• - severe spondylolisthesis spinal canal? AP
  diameter elongate and sagittal plane?? spinal
  canal narrowing??.
• Imaging
• - CT test of choice to diagnose, pars?
  sclerosis and fracture
• - MRI ??? ?????, actual fracture? ???? ??? ??
  ??.

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• - MRI? foraminal stenosis? nerve root
  compression? ? ??
• pars fracture????? cartilagenous overgrowth
  ??.
• - plain film? oblique projection??
  spondylolisthesis? ?? ??? ? ??, bone detail? MRI
  exam? ?????? ???